Provider Demographics
NPI:1770502288
Name:WALTON, ROY P (CNS)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:P
Last Name:WALTON
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 SPENCERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4230
Mailing Address - Country:US
Mailing Address - Phone:419-222-5788
Mailing Address - Fax:419-222-9504
Practice Address - Street 1:1301 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3121
Practice Address - Country:US
Practice Address - Phone:419-222-5788
Practice Address - Fax:419-222-9504
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS-04248364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWANS02111Medicare ID - Type Unspecified
OHP55593Medicare UPIN